Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage

Abstract

Artículo de publicación ISIBackground Whether rapid lowering of elevated blood pressure would improve the outcome in patients with intracerebral hemorrhage is not known. Methods We randomly assigned 2839 patients who had had a spontaneous intracerebral hemorrhage within the previous 6 hours and who had elevated systolic blood pressure to receive intensive treatment to lower their blood pressure (with a target systolic level of <140 mm Hg within 1 hour) or guideline-recommended treatment (with a target systolic level of <180 mm Hg) with the use of agents of the physician’s choosing. The primary outcome was death or major disability, which was defined as a score of 3 to 6 on the modified Rankin scale (in which a score of 0 indicates no symptoms, a score of 5 indicates severe disability, and a score of 6 indicates death) at 90 days. A prespecified ordinal analysis of the modified Rankin score was also performed. The rate of serious adverse events was compared between the two groups. Results Among the 2794 participants for whom the primary outcome could be determined, 719 of 1382 participants (52.0%) receiving intensive treatment, as compared with 785 of 1412 (55.6%) receiving guideline-recommended treatment, had a primary outcome event (odds ratio with intensive treatment, 0.87; 95% confidence interval [CI], 0.75 to 1.01; P = 0.06). The ordinal analysis showed significantly lower modified Rankin scores with intensive treatment (odds ratio for greater disability, 0.87; 95% CI, 0.77 to 1.00; P = 0.04). Mortality was 11.9% in the group receiving intensive treatment and 12.0% in the group receiving guideline-recommended treatment. Nonfatal serious adverse events occurred in 23.3% and 23.6% of the patients in the two groups, respectively. Conclusions In patients with intracerebral hemorrhage, intensive lowering of blood pressure did not result in a significant reduction in the rate of the primary outcome of death or severe disability. An ordinal analysis of modified Rankin scores indicated improved functional outcomes with intensive lowering of blood pressure

Blood Pressure Reduction Does Not Reduce Perihematoma Oxygenation: A CT Perfusion Study

“…They are also consistent with larger trials in ICH, which indicate that rapid BP reduction is not associated with worse clinical outcomes. 33,34 This study has a number of limitations. Estimation of OEF max using CTP source data is an indirect measurement, based on the flow , maximum cerebral metabolic rate of oxygen; OEF max , maximum oxygen extraction fraction.…”

Evaluation of Acute Kidney Injury and Mortality After Intensive Blood Pressure Control in Patients With Intracerebral Hemorrhage

“…Methodological differences between our retrospective analysis and the larger gold standard trials, INTERACT 24 and ATACH 2,6 also may limit our conclusions and applications. Our sample size was modest, retrospectively evaluated, and nonrandomized, with a significant number of patients removed because of inadequate renal monitoring.…”

“…A rightward shift in cerebral autoregulation may occur because of both chronic hypertension19 and stroke 20. Although the results of INTERACT 2 appeared to contradict the long‐standing belief that intensive SBP control would exacerbate perihematomal ischemia,4 cautious and stepwise blood pressure reduction has long been recommended in the management of malignant hypertension21, 22 and hypertensive encephalopathy 8, 10, 23. The current American Heart Association/American Stroke Association guidelines do not offer recommendations on SBP reduction in patients presenting with SBPs >220 mm Hg.…”

“…However, the ideal target for systolic blood pressure (SBP) reduction, particularly for patients presenting with extremely high SBP (≥220 mm Hg), remains unclear. The multicenter randomized INTERACT 2 (Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial) showed a trend suggesting intensive SBP reduction targeted to <140 mm Hg leads to improved clinical outcome 4. As a result, this goal was adopted by the American Heart Association/American Stroke Association recommendations for acute ICH management 5.…”

Intensive blood-pressure lowering in patients with acute cerebral hemorrhage

“…The rate of death or disability among patients randomly assigned to intensive reduction in the systolic bloodpressure level, with a target systolic blood pressure of less than 140 mm Hg within 1 hour, was nonsignificantly lower than the rate among those assigned to guideline-recommended treatment, with a target systolic blood pressure of less than 180 mm Hg, with the use of a variety of antihypertensive medications (absolute difference, 3.6 percentage points; P = 0.06). 5 We designed the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial 6 to determine the efficacy of rapidly lowering the systolic blood-pressure level in patients in an earlier time window after symptom onset than that evaluated in previous trials. 4,5,7 The trial was based on evidence that hematoma expansion and the rate of subsequent death or disability might be reduced with very early and more aggressive reduction in the systolic blood-pressure level 8,9 among persons at high risk owing to a high systolic blood-pressure level (≥170 mm Hg10 to ≥200 mm Hg 11 ) at presentation.…”